Book Reviews

    Bone and Joint Futures Anthony D. Woolf, BMJ books, ISBN 0727915487, £16.95

The Bone and Joint decade was formally launched in January 2000 at the headquarters of the World Health Organisation in Switzerland. Therefore, it is appropriate this small book has been produced discussing the future prospects for bone and joint diseases.

The book is inevitably a broad brush approach to musculoskeletal problems. It covers eight main areas of interest including trauma, osteoarthritis, rheumatoid arthritis, osteoporosis and chronic musculoskeletal pain. It includes an assessment of the future burden of bone and joint conditions and also discusses some of the potential benefits from recent developments in the basic sciences.

The initial chapter dealing with future provision of care for musculoskeletal conditions written by the Editor sets the scene for the rest of the book. He discusses the burden that these conditions cause to individuals and society, and then goes on to discuss the health care needs and the goals of management. Against this background he looks at what can be done in treating these conditions at the moment, and finally looks at future demand and various models for the provision of health care as well as some of the potential mechanisms for managing these problems.

In the second chapter again a very broad approach is taken starting with a review of the global burden of disease project which is commissioned by the world bank in 1993.

Dr Simmonds makes the point that epidemiological and demographic data bases for many countries and diseases are weak and even for the three musculoskeletal disorders chosen, namely rheumatoid arthritis, osteoarthritis of the hip and osteoarthritis of the knee, there are some regions of the world for which data is very sparse. Nonetheless, the information available provides a starting point for speculations about future changes in the burden of bone and joint conditions.

Of particular interest was the section on back pain where Dr Simmonds makes the point that in Britain outpatient clinic attendances for back pain rose five fold in the decade up to 1993. The prevalence of back pain does vary significantly in developing countries and the question is whether this is a real difference or does it arise because of differences of perception and translation in the terminology used to describe the condition.

Subsequent chapters dealing with rheumatoid arthritis, osteoarthritis and osteoporosis provide useful information for clinicians and policy makers when they consider these conditions that are likely to increase significantly over the next few years.

Mr I.K. Ritchie 
Stirling Royal Infirmary 
Stirling 
U.K.

Fundamental Techniques of Plastic Surgery and Other Surgical Applications, Tenth Edition by AD McGregor & IA McGregor
 Churchill Livingston, ISBN 0443 063729, £49.95

This is the tenth edition of the wellestablished standard textbook of fundamental techniques of plastic surgery addressed to all levels of plastic surgeons but, particularly, to those training and surgeons in other specialties. It continues the tradition of being a multi-author text. It was intended to be co-authored by Alan McGregor and his father but unfortunately Ian died suddenly and prematurely on 13 April 1998. His style and clarity is evident throughout the book.

The basic format is the same as earlier versions. There are no drastic changes apart from the fact that maxillo-facial surgery has been left out. The book is now concerned solely with issues which relate to management and repair or reconstruction of defects and wounds by use of skin or other tissues. The general layout of the book is clearer and most of the illustrations have been re-drawn but with little basic change.

The section on flaps, particularly the vascular aspects, have been greatly improved and expanded whilst maintaining discussion of traditional methods which are more useful in emergency situations and in restricted circumstances. The section on muscle and musculo-cutaneous flaps has been reduced and downgraded, however. There is a new chapter entitled “Additional Techniques” which briefly mentions tissue expansion, liposuction and lasers and this should be expanded in future editions.

Overall, this continues to be an excellent book for the surgeon-intraining and is highly recommended. I would hope, however, that in future editions, there will be some expansion of the text. It would be useful, particularly, in the era of sub-specialisation, if a co-author or other contributor, e.g. on breast reconstruction could be drafted in. This would be beneficial and there might be a case for completeness to re-instate a chapter on maxillo-facial surgery, as the use of multidisciplinary teams in modern treatment should broaden the scope of a textbook such as this.

I found this book a source of useful information. Many of the topics will form a background over the next ten to twenty years as we consider how to organise services for our patients.

Mr A.M. Morris
Ninewells Hospital
Dundee 
U.K.

Clinical and Diagnostic Pathology of Graft-Versus-Host Disease, Edited by Professor Dr Berno Heymer, 
Springer, ISBN 3540677194, £49.00

The reduction in relapse risk for leukaemia and other malignancies resulting from the therapeutic use of allogeneic stem cell transplantation (allo-SCT) is mediated predominantly by donor T-cells. This so called graftversusmalignancy (GVM) effect has cured many patients, however, the strongly associated graft-versus-host disease (GVHD), which is also Tcell mediated, has been responsible for the high mortality and morbidity associated with these procedures. The Holy Grail of allo-SCT is to separate these two biological processes and so harness the GVM effect whilst eliminating GVHD. Improvements in our understanding of immunology and progress in clinical graft engineering suggest that this is an obtainable goal. However, at present the management of GVHD remains an important remit of the transplant team. Lying at the heart of this is timely and robust diagnosis.

With this in mind this text is predominantly aimed at pathologists who are asked to diagnose GVHD from skin, liver, bowel or other tissue biopsies. The undoubted strengths of the book lie in the clarity of presentation and superb histological prints, (which appealed to me as a non histopathologist!), the size of the book, which at 149 pages including references is very manageable, but most importantly the frank way in which the data are presented. The authors set out to describe the clinico-pathological features of GVHD in an era where prophylactic immunosuppression and earlier treatment of suspected GVHD makes interpretation of biopsies, based on classical features from the pioneering days of allo-SCT, more difficult. Detailed descriptions of organ specific acute and chronic GVHD are based on 20 years of day -to -day experience and hence are honest, real life interpretations of what can and cannot be achieved histologically. Furthermore, when the transplant physician asks, “is this illness GVHD?” it is invariably in the context of a sick patient manifesting one or more of the affects of total body irradiation, high dose chemotherapy or intensive immunosuppression.

The patient is also on many drugs, especially antibiotics, and at high risk of viral and other opportunistic infections. The histological manifestations of GVHD and these co-morbid conditions overlap making a firm diagnosis difficult. With this in mind, the differential diagnosis of acute GVHD is well defined, with emphasis on identifying helpful histological features in each tissue, as distinct from non-specific unhelpful ones associated with co-morbidity. The spectrum of disease from early to late is covered by extensive use of photomicrographs. There is a table to guide clinicians considering a skin biopsy to diagnose GVHD. It outlines the pathologist’s wish list in terms of optimal timing after the transplant, the need for repeat biopsies and a pretransplant skin biopsy for patients with pre-transplant skin disease. It reads, as a “plea from the heart,” generated no doubt by countless tiny tissue biopsies taken randomly and delivered with insufficient background information, but with great expectations!

In an era where the reluctance of pathologists to commit themselves to a firm diagnosis of lymphoma without a barrage of immunophenotyping data has become the hallmark of the clinico-pathological-case conference, the conclusions on the limited value of immunohistochemistry data in GVHD were refreshing. To be fair to pathologists, the authors point out the difference between malignancy, which lends itself to an immunological approach and inflammation which does not. However, despite GVHD falling into this latter category, immunohistochemistry has provided some insights into the roles of lymphocyte subsets and other inflammatory cells in the manifestations of GVHD. Most importantly it confirms the role of CD3+ T-cells in the inflammatory cell infiltrate. However, descriptions and images of the homing of OPD4+ cells predominantly to the dermis and the CD8+ cells to the epidermis in acute skin GVHD, emphasised to me the complexity of GVHD pathology.

Are there any omissions from the book? Well not really. However, for a book based on describing GVHD diagnosis in the modern era, I was surprised not to find mention of non-myeloablative (mini) allografts. Clinically, these protocols based on intensive T-cell immunosuppression rather than myeloablation, do produce different patterns of GVHD in terms of timing and severity. However, whether or not they lead to novel histological variants of GVHD remains uncertain.

Finally, the most impressive aspect of this book is the illustrations. The presentation of the histology is superb with details such as “exploding crypts” and single cell apoptosis clearly identified by arrows placed in unequivocal positions accompanied by relevant figure legends. The authors should certainly consider producing a slide atlas to go with the book as this would be an outstanding teaching aid. In the Preface Professor Heymer states that “A medical book need not be pretty, but it must be necessary and informative....” In the final analysis, Clinical and Diagnostic Pathology of Graft-versus-Host Disease has managed to be very informative predominantly through the quality of the illustrations, and I am sure to pathologists they are indeed pretty!

Dr Dominic J. Culligan
Aberdeen Royal Infirmary 
Aberdeen 
U.K.

Clinical Opthalmic Pathology - Principles of Diseases of the Eye and Associated Structures, Edited by John Harry & Gary Mission, Harcourt Publishers Ltd, ISBN 0750621710, £125.00

This new addition to the range of textbooks on ophthalmic pathology is the joint work of a consultant opthalmologist and an experienced ophthalmic pathologist. The combination works well and has resulted in a textbook which is clearly written and focuses on clinically relevant conditions. The text is aimed at ophthalmic trainees, both opthalmologists and optometrists, particularly those preparing for professional exams.

The strength of this textbook lies in its approach to diseases processes. Rather than taking a more traditional anatomical division of pathology the authors have employed a mechanistic approach, concentrating on the pathogenesis of various ophthalmic diseases in sections dealing with pathological processes. In doing so, the authors promote an understanding of the underlying disease processes in the conditions encountered by the practicing opthalmologist.

Sections 1-5 cover a spectrum of disease mechanisms whilst the following two sections deal with vascular, haematological and neural conditions in a more conventional manner. The authors are to be commended on including an entire section on the influence of genetics in ophthalmic practice. This introduction will undoubtedly prove valuable to the reader as molecular analysis of disease processes alters and redefines our understanding of many clinical conditions in the future.

The book itself is well presented and the format is enhanced by the ample use of tables throughout the text. The illustrations of macroscopic and microscopic pathology, so crucial to such a textbook, are extremely good. These might have been enhanced by the use of arrows or other appropriate markers to point out important aspects of the pathology.

The concluding section on the clinician and the laboratory is appropriate not only for trainees, but provides a valuable reference for opthalmologists dealing with various pathological specimens in the clinical environment.

The authors provide a list of textbooks as further reading. It would have been valuable to have additionally provided key references for the pathologies studied to guide the non-expert through what can often be a vast and daunting basic science literature. This criticism, however, is minor and overall this textbook provides a comprehensive, clear and well illustrated reference both for trainees and practicing clinicians who require up-to-date and clinically relevant information on the diverse types of pathology seen in ophthalmology.

Mr D.G. Charteris
Vitreretinal Unit
Moorfields Eye Hospital 
London 
U.K.

ABC of Spinal Cord Injury, Fourth Edition, Edited by David Grundy & Andrew Swain, BMJ Books, ISBN 0727915185, £16.95

This is one of the essential texts for anyone involved in trauma. Spinal cord injury is relatively rare but its consequences for the individual, family and society are immense. It is important that anyone who has to deal with such an injured patient should have accurate information readily at hand in order to be able to provide the patient with the best possible service but also to ensure that all others such as seriously worried relatives do receive the correct and up to date knowledge. Unfortunately, only a small proportion of these seriously injured patients will be transferred to a specialised centre so that it is vital that the doctor who has to deal with the emergency admission is able to discuss the further care of the patient through to discharge home. Rehabilitation starts with the first medical intervention.

The previous editions of this work, which emanates from the team at the Duke of Cornwall Spinal Treatment Centre, were invaluable sources of information but this fourth edition is presented in a new and much more acceptable style that will increase its appeal and hopefully encourage its study.

The reader is taken through the process of care from the accident situation, investigation, (including a useful reminder of surgical anatomy) to management of the injury and of the expected complications associated with the neurological dysfunction. The importance of a full clinical and neurological examination is demonstrated. The use of the Standard Neurological Classification of Spinal Cord Injury as agreed by the American Spinal Injury Association and the International Medical Society of Paraplegia has a great prospect of improving communication between centres and also of allowing a much improved audit of outcome or of treatment. The quality of outcome often will depend on that initial assessment and on the early care. Guttmann at Stoke Mandeville fifty years ago demonstrated the importance of good nursing and this subject is well addressed as are the associated therapies which together combine to provide the patient with a team based comprehensive treatment plan.

Well managed spinal cord injured patients may have a near normal survival in terms of years and so the later aspects and the management of late complications such as chronic pain and ventilatory problems are well discussed. A new chapter in this edition is on the management of spinal cord injury in developing countries where a high incidence and poor financial resources create huge problems. This chapter really is addressed to the politicians. However, appropriate technology does not need to be expensive and where labour costs are low a manual turning team can achieve even more than an electric bed by adding the value of human contact. There will be scope in future editions to develop the practicalities of this theme.

A short text must be didactic but the editors have hedged their bets on the use of high-dose steroids in the acute injury. Suffice to say that all spinal units are familiar with the complications of steroid therapy but any demonstration of positive value has yet to appear.

This is a very valuable, concise, text written by experts and should be compulsory reading for all doctors and nurses dealing with trauma. It is essential reading, not only for examinations, but if the precepts of this book were followed the severity of an awful injury often would be reduced. A wise government would issue it to all concerned with spinal cord care.

Mr Peter Edmond
Pickering 
U.K.

    Recent Advances in Surgery, Edited by C. Johnson & I. Taylor, Royal Society of Medicine Press, 
                             ISBN 185315508X, £32.95

The current edition of Recent Advances in Surgery continues the successful format of reviews of trends over a wide-ranging field of surgical specialities. As in previous series, it is thoughtfully presented and gives an excellent review of the topics, which tend to remain controversial. The chapter on post-operative pain control was particularly enjoyable, giving a very clear and expert review of a subject which junior trainees still, at times, find problematic. The chapter on peri-operative nutritional support was also very interesting and along with many chapters in this book, the authors managed to give a very balanced view of current thoughts and are not afraid to challenge established trends, which have often little evidence base. The key points throughout the book are particularly helpful in this regard.

I particularly enjoyed the chapter on oral carcinoma and other topics outwith my own particular field of interest. Whilst highlighting these few chapters, this does not, in any way, detract from the quality and enjoyment of the other topics in the current series. The final chapter on recent randomised controlled trials is again particularly helpful for trainees who would wish to find a brief summary of the issues currently attracting major interest.

I have read this series since its inception and continue to enjoy the style and content of which has been so successful. I think it is essential reading for both the trainee and trained surgeon and I look forward to the next edition.

Mr W.S. Hendry
Stirling Royal Infirmary
Stirling 
U.K.

Major Incident Management System The Scene Aide Memoire for Major Incident Medical Management and Support, by T.J. Hodgetts & C. Porter, BMJ Books, ISBN 0727916149, £30.00

This is a useful contribution to the literature on the practical management of major incidents. It is based on course work for the Major Incident Management and Supportive Courses (MIMMS) that proved so popular in the last decade. Hodgett and Porter draw heavily on their experience teaching the courses and in managing incidents. Students looking for generic core educational material will not find it here since this is essentially an aide memoire to practical management at the scene of an incident. It clearly outlines the command and control chain and the doctor and paramedic’s relationship within it and to the other rescue services.

Doctors undertaking the role of Crowd Doctor or Major Incident Medical Officer will find the information clear and helpful and the paramedic will find it a useful contribution to his everyday activity. The step-by-step guidance on how to proceed at a major incident is set out in an easy to follow way.

Criticism which can be made is that the volume is bulky and, if it is meant to be an aide memoire to be used at the scene, it would benefit from production in a smaller more compact form.

The only other comment is that nowhere is there advice to doctors and medical incident officers to keep a contemporaneous note of clinical decisions taken and administrative arrangements on a Dictaphone tape which may be more practical than handwriting at the scene and which is now an acceptable record of clinical or administrative activity at a major incident scene.

Mr R. Myles Gibson 
Harley Street 
London 
U.K.